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Summary

For more than 100 years doctors have been coming to us for advice. Now you can, too.TheMerck Manualhas traditionally provided exclusive, up-to-the-minute information to doctors, nurses, and other healthcare professionals. Now, with the special Home Edition, the general public can access virtually the same critical data contained in the physician's version -- but in everyday language and a reader-friendly format.With contributions from nearly 200 internationally respected medical experts, this fully revised edition offers vital, easy-to-understand information about almost every known medical issue, including: AIDS cancer eating, digestive, and nutrition disorders heart disease mental illness pediatric care -- including a new chapter on early-childhood development sexual dysfunction terminal illness viruses and infections...and much more. Featuring original illustrations and diagrams, an A-Z listing of brand-name and generic drugs, and an appendix of medical resources,The Merck Manual -- Home Editionis published as a not-for-profit service by Merck, a world leader in breakthrough medical discoveries with a long commitment to making the world a healthier place.

Table of Contents

A Guide for Readers

p. liii

Understanding Medical Terms

p. lv

Fundamentals

p. 1

The Human Body

p. 1

Genetics

p. 7

The Aging Body

p. 14

Communicating With Health Care Professionals

p. 19

Prevention

p. 22

Exercise and Fitness

p. 27

Rehabilitation

p. 32

Death and Dying

p. 41

Legal and Ethical Issues

p. 48

Drugs

p. 53

Overview of Drugs

p. 53

Drug Administration and Kinetics

p. 57

Drug Dynamics

p. 62

Factors Affecting Response to Drugs

p. 66

Drugs and Aging

p. 70

Adverse Drug Reactions

p. 73

Compliance With Drug Treatment

p. 76

Trade-Name and Generic Drugs

p. 79

Over-the-Counter Drugs

p. 82

Medicinal Herbs and Nutraceuticals

p. 92

Heart and Blood Vessel Disorders

p. 101

Biology of the Heart and Blood Vessels

p. 101

Symptoms and Diagnosis of Heart and Blood Vessel Disorders

p. 105

High Blood Pressure

p. 117

Low Blood Pressure

p. 126

Shock

p. 132

Heart Failure

p. 134

Cardiomyopathy

p. 142

Abnormal Heart Rhythms

p. 146

Heart Valve Disorders

p. 157

Infective Endocarditis

p. 165

Pericardial Disease

p. 168

Heart Tumors

p. 172

Atherosclerosis

p. 174

Coronary Artery Disease

p. 178

Peripheral Arterial Disease

p. 194

Aneurysms and Aortic Dissection

p. 203

Venous Disorders

p. 208

Lymphatic Disorders

p. 216

Lung and Airway Disorders

p. 219

Biology of the Lungs and Airways

p. 219

Symptoms and Diagnosis of Lung Disorders

p. 223

Pulmonary Rehabilitation

p. 233

Bronchitis

p. 236

Pneumonia

p. 237

Lung Abscess

p. 245

Asthma

p. 246

Chronic Obstructive Pulmonary Disease

p. 253

Pulmonary Embolism

p. 257

Bronchiectasis

p. 260

Atelectasis

p. 263

Occupational Lung Diseases

p. 265

Infiltrative Lung Diseases

p. 271

Allergic Diseases of the Lungs

p. 278

Pleural Disorders

p. 282

Cystic Fibrosis

p. 286

Pulmonary Hypertension

p. 290

Respiratory Failure

p. 293

Acute Respiratory Distress Syndrome

p. 294

Lung Cancer

p. 296

Bone, Joint, and Muscle Disorders

p. 300

Biology of the Musculoskeletal System

p. 301

Symptoms and Diagnosis of Musculoskeletal Disorders

p. 304

Osteoporosis

p. 308

Paget's Disease of Bone

p. 311

Fractures

p. 313

Bone Tumors

p. 323

Avascular Necrosis of the Bone

p. 325

Bone and Joint Infections

p. 327

Osteoarthritis

p. 330

Rheumatoid Arthritis and Other Types of Inflammatory Arthritis

p. 333

Autoimmune Disorders of Connective Tissue

p. 340

Vasculitic Disorders of Connective Tissue

p. 348

Gout and Pseudogout

p. 353

Hand Disorders

p. 356

Foot Problems

p. 364

Muscular Dystrophy and Related Disorders

p. 372

Disorders of Muscles, Bursas, and Tendons

p. 375

Sports Injuries

p. 379

Brain, Spinal Cord, and Nerve Disorders

p. 389

Biology of the Nervous System

p. 390

Diagnosis of Brain, Spinal Cord, and Nerve Disorders

p. 395

Pain

p. 402

Headaches

p. 411

Dizziness and Vertigo

p. 416

Sleep Disorders

p. 421

Brain Dysfunction

p. 428

Delirium and Dementia

p. 433

Stupor and Coma

p. 443

Seizure Disorders

p. 447

Stroke

p. 454

Head Injuries

p. 463

Tumors of the Nervous System

p. 469

Infections of the Brain and Spinal Cord

p. 478

Prion Diseases

p. 490

Movement Disorders

p. 492

Multiple Sclerosis and Related Disorders

p. 504

Spinal Cord Disorders

p. 508

Low Back Pain

p. 515

Peripheral Nerve Disorders

p. 521

Cranial Nerve Disorders

p. 534

Smell and Taste Disorders

p. 539

Mental Health Disorders

p. 542

Overview of Mental Health Care

p. 542

Somatoform Disorders

p. 546

Anxiety Disorders

p. 549

Depression and Mania

p. 557

Suicidal Behavior

p. 565

Eating Disorders

p. 567

Sexuality

p. 570

Personality Disorder

p. 573

Amnesia and Related Disorders

p. 578

Schizophrenia and Delusional Disorder

p. 582

Drug Use and Abuse

p. 587

Mouth and Dental Disorders

p. 601

Biology of the Mouth

p. 601

Lip and Tongue Disorders

p. 603

Salivary Gland Disorders

p. 605

Mouth Sores

p. 606

Growths in the Mouth

p. 609

Tooth Disorders

p. 612

Periodontal Diseases

p. 619

Temporomandibular Disorders

p. 623

Urgent Dental Problems

p. 627

Digestive Disorders

p. 630

Biology of the Digestive System

p. 630

Symptoms and Diagnosis of Digestive Disorders

p. 634

Disorders of the Esophagus

p. 642

Peptic Disorders

p. 646

Gastroenteritis

p. 654

Hiatus Hernia, Bezoars, and Foreign Bodies

p. 661

Pancreatitis

p. 663

Malabsorption

p. 667

Inflammatory Bowel Diseases

p. 671

Antibiotic-Associated Colitis

p. 678

Diverticular Disease

p. 679

Bowel Movement Disorders

p. 682

Disorders of the Anus and Rectum

p. 691

Tumors of the Digestive System

p. 696

Gastrointestinal Emergencies

p. 707

Liver and Gallbladder Disorders

p. 715

Biology of the Liver and Gallbladder

p. 715

Diagnostic Tests for Liver and Gallbladder Disorders

p. 717

Clinical Manifestations of Liver Disease

p. 720

Fatty Liver, Cirrhosis, and Related Disorders

p. 725

Hepatitis

p. 729

Blood Vessel Disorders of the Liver

p. 733

Liver Tumors

p. 737

Gallbladder Disorders

p. 740

Kidney and Urinary Tract Disorders

p. 744

Biology of the Kidneys and Urinary Tract

p. 744

Symptoms and Diagnosis of Kidney and Urinary Tract Disorders

p. 747

Kidney Failure

p. 752

Nephritis

p. 760

Blood Vessel Disorders of the Kidneys

p. 767

Tubular and Cystic Kidney Disorders

p. 771

Urinary Incontinence

p. 778

Urinary Tract Obstruction

p. 783

Urinary Tract Infections

p. 787

Injury to the Urinary Tract

p. 792

Cancers of the Kidney and Urinary Tract

p. 795

Disorders of Nutrition and Metabolism

p. 799

Overview of Nutrition

p. 799

Undernutrition

p. 806

Vitamins

p. 809

Minerals and Electrolytes

p. 818

Obesity

p. 831

Disorders of Cholesterol

p. 836

Water Balance

p. 842

Acid-Base Balance

p. 845

Porphyrias

p. 847

Hormonal Disorders

p. 851

Biology of the Endocrine System

p. 851

Pituitary Gland Disorders

p. 853

Thyroid Gland Disorders

p. 860

Adrenal Gland Disorders

p. 868

Diabetes Mellitus

p. 873

Hypoglycemia

p. 881

Multiple Endocrine Neoplasia Syndromes

p. 883

Carcinoid Tumors

p. 884

Blood Disorders

p. 886

Biology of Blood

p. 886

Symptoms and Diagnosis of Blood Disorders

p. 888

Blood Transfusion

p. 890

Anemia

p. 894

Bleeding and Clotting Disorders

p. 902

White Blood Cell Disorders

p. 908

Plasma Cell Disorders

p. 912

Leukemias

p. 916

Lymphomas

p. 922

Myeloproliferative Disorders

p. 928

Spleen Disorders

p. 931

Cancer

p. 935

Overview of Cancer

p. 935

Symptoms and Diagnosis of Cancer

p. 938

Prevention and Treatment of Cancer

p. 944

Immune Disorders

p. 950

Biology of the Immune System

p. 950

Immunodeficiency Disorders

p. 956

Allergic Reactions

p. 962

Autoimmune Disorders

p. 971

Transplantation

p. 973

Infections

p. 982

Biology of Infectious Disease

p. 982

Immunization

p. 988

Bacterial Infections

p. 990

Bacteremia, Sepsis, and Septic Shock

p. 1012

Antibiotics

p. 1014

Tuberculosis

p. 1018

Leprosy

p. 1022

Rickettsial and Ehrlichial Infections

p. 1024

Parasitic Infections

p. 1027

Fungal Infections

p. 1039

Viral Infections

p. 1044

Human Immunodeficiency Virus Infection

p. 1057

Sexually Transmitted Diseases

p. 1064

Skin Disorders

p. 1073

Biology of the Skin

p. 1073

Diagnosis and Treatment of Skin Disorders

p. 1075

Itching and Noninfectious Rashes

p. 1078

Acne

p. 1090

Pressure Sores

p. 1093

Sweating Disorders

p. 1095

Hair Disorders

p. 1096

Pigment Disorders

p. 1098

Blistering Diseases

p. 1100

Parasitic Skin Infections

p. 1102

Bacterial Skin Infections

p. 1103

Fungal Skin Infections

p. 1108

Viral Skin Infections

p. 1111

Sunlight and Skin Damage

p. 1112

Noncancerous Skin Growths

p. 1115

Skin Cancers

p. 1119

Ears, Nose, and Throat Disorders

p. 1123

Biology of the Ears, Nose, and Throat

p. 1123

Hearing Loss and Deafness

p. 1126

Outer Ear Disorders

p. 1131

Middle and Inner Ear Disorders

p. 1134

Disorders of the Nose and Sinuses

p. 1139

Throat Disorders

p. 1144

Nose and Throat Cancers

p. 1147

Eye Disorders

p. 1151

Biology of the Eyes

p. 1151

Symptoms and Diagnosis of Eye Disorders

p. 1154

Refractive Disorders

p. 1161

Eye Injuries

p. 1164

Eyelid and Tear Gland Disorders

p. 1167

Disorders of the Conjunctiva and Sclera

p. 1170

Corneal Disorders

p. 1173

Cataract

p. 1176

Uveitis

p. 1178

Glaucoma

p. 1179

Retinal Disorders

p. 1182

Optic Nerve Disorders

p. 1187

Eye Socket Disorders

p. 1189

Men's Health Issues

p. 1192

Male Reproductive System

p. 1192

Disorders of the Penis and Testes

p. 1194

Prostate Disorders

p. 1199

Sexual Dysfunction

p. 1205

Women's Health Issues

p. 1211

Biology of the Female Reproductive System

p. 1212

Symptoms and Diagnosis of Gynecologic Disorders

p. 1217

Menopause

p. 1224

Menstrual Disorders and Abnormal Vaginal Bleeding

p. 1229

Endometriosis

p. 1235

Fibroids

p. 1238

Vaginal Infections

p. 1240

Pelvic Inflammatory Disease

p. 1243

Pelvic Floor Disorders

p. 1245

Sexual Dysfunction

p. 1247

Breast Disorders

p. 1252

Cancers of the Female Reproductive System

p. 1265

Violence Against Women

p. 1274

Infertility

p. 1277

Family Planning

p. 1282

Detection of Genetic Disorders

p. 1291

Normal Pregnancy

p. 1296

High-Risk Pregnancy

p. 1305

Drug Use During Pregnancy

p. 1318

Normal Labor and Delivery

p. 1323

Complications of Labor and Delivery

p. 1329

Postdelivery Period

p. 1334

Children's Health Issues

p. 1339

Normal Newborns and Infants

p. 1340

Problems in Newborns

p. 1350

Birth Defects

p. 1365

Chromosomal and Genetic Abnormalities

p. 1380

Problems in Infants and Very Young Children

p. 1383

Normal Preschool and School-Aged Children

p. 1390

Behavioral and Developmental Problems in Young Children

p. 1395

Normal Adolescents

p. 1403

Problems in Adolescents

p. 1405

Bacterial Infections

p. 1410

Viral Infections

p. 1418

Respiratory Disorders

p. 1431

Digestive Disorders

p. 1434

Ear, Nose, and Throat Disorders

p. 1441

Eye Disorders

p. 1447

Bone Disorders

p. 1449

Hereditary Connective Tissue Disorders

p. 1453

Juvenile Rheumatoid Arthritis

p. 1457

Diabetes Mellitus

p. 1458

Hereditary Disorders of Metabolism

p. 1461

Childhood Cancers

p. 1466

Cerebral Palsy

p. 1469

Mental Retardation

p. 1471

Mental Health Disorders

p. 1474

Social Issues Affecting Children and Their Families

p. 1481

Child Neglect and Abuse

p. 1486

Accidents and Injuries

p. 1490

Burns

p. 1490

Heat Disorders

p. 1494

Cold Injuries

p. 1496

Radiation Injury

p. 1499

Electrical and Lightning Injuries

p. 1503

Near Drowning

p. 1506

Diving and Compressed Air Injuries

p. 1507

Altitude Illness

p. 1512

Poisoning

p. 1514

Bites and Stings

p. 1521

First Aid

p. 1527

Special Subjects

p. 1533

Medical Decision Making

p. 1533

Surgery

p. 1536

Complementary and Alternative Medicine

p. 1541

Travel and Health

p. 1545

Amyloidosis

p. 1551

Familial Mediterranean Fever

p. 1552

Diseases of Unknown Cause

p. 1553

Appendixes

p. 1557

Weights and Measures

p. 1557

Common Medical Tests

p. 1559

Drug Names: Generic and Trade

p. 1566

Resources for Help and Information

p. 1592

Index

p. 1607

Table of Contents provided by Ingram. All Rights Reserved.

Excerpts

Air Travel and Medical Problems

Traveling by air can cause or worsen a variety of medical conditions, although very few conditions would prevent a person from flying. Those that may prevent flying include a pneumothorax, lung damage from tuberculosis, diseases that could be spread to other passengers, and conditions in which even a small expansion of air would damage tissues, such as intestinal surgery in the previous 10 days. Some conditions require planning and taking precautions before a flight. For example, people who have had a colostomy should wear a large bag and anticipate frequent filling.

Air travel poses problems related to changes in air pressure, reduced amounts of oxygen, turbulence, disruptions of the body's internal 24-hour (circadian) clock (jet lag), and psychologic or physical stress.

Changes in Air Pressure

Modern jet airplanes maintain air pressure inside the cabin (cabin pressure) at low levels, equivalent to the atmospheric pressure at 5,000 to 8,000 feet. At such levels, air trapped in pockets within the body - such as in the lungs, inner ear, sinuses, and intestinal tract - expands by about 25 percent. This expansion sometimes aggravates certain medical conditions, such as emphysema, blocked eustachian tubes, chronic sinusitis, and chronic gas pains. Problems may be particularly severe when an airplane accidentally loses cabin pressure or when the cabin isn't pressurized, as is the case with some smaller airplanes.

A sensation of pressure in the ears is common during airplane flights. It develops as the difference between pressure outside the ear and inside the ear increases, causing the eardrum to bulge. Eventually, the pressure equalizes when the eustachian tube (a passage that connects the middle ear with the back of the nose) allows air to flow in and out of the middle ear. Head colds or allergies may produce fluid and swelling that block the eustachian tube, and repeated infections may result in scarring that partially blocks it. Then air becomes trapped in the middle ear, producing pressure (barotitis media) and pain. Rarely, the eardrum ruptures. Similarly, air may be trapped in the sinuses (barosinusitis), causing facial pain.

Swallowing frequently or yawning during the airplane's descent and taking decongestants before or during the flight can prevent or relieve these conditions. Because children are particularly susceptible to barotitis media, they should chew gum, suck hard candy, or drink something during ascent and descent to encourage swallowing; babies can be nursed or given a bottle or pacifier.

Reduced Oxygen

The relatively low air pressure inside an airplane also causes problems because of its effect on oxygen levels. Low oxygen levels are particularly troublesome for people who have a severe lung disease such as emphysema or cystic fibrosis, heart failure, severe anemia, severe angina, sickle cell disease, or certain congenital heart diseases. Usually, such people can fly safely if provided with oxygen. Airlines can handle a request for oxygen if notified 72 hours in advance of a flight. People generally may fly 10 to 14 days after a heart attack. During flight, people who have breathing problems should not smoke or drink alcohol - which aggravates the effects of reduced oxygen. In general, anyone who can walk 100 yards or climb one flight of stairs should be able to tolerate normal cabin conditions without additional oxygen.

Turbulence

Turbulence can cause air sickness or an injury. People who are prone to air sickness may benefit from dimenhydrinate taken as a tablet or scopolamine applied to the skin as a patch. However, these drugs may cause adverse effects, particularly in the elderly The patches cause fewer adverse effects. To prevent injuries, passengers should keep their seat belts fastened while seated.

Jet Lag

Rapid travel across several time zones produces many physical and psychologic stresses known as jet lag (circadian dysrhythmia). A gradual shift in eating and sleeping patterns before departure may alleviate the problem. Some medication schedules may have to be adjusted; for example, the intervals between drugs normally taken at precise times throughout the day should be based on elapsed time - - such as every 8 hours -rather than on local time. People who have diabetes and who use long-acting insulin may switch to regular insulin until they've adjusted to the new time zone, food, and activity level, or they may make up the difference in time zone changes over several days. They should work out a medication and eating schedule with their doctor before departure and take with them a device to monitor blood sugar (glucose) levels.

Melatonin, a hormone that regulates the sleepwake cycle, is reported to help with sleep disturbances caused by jet lag. Its effectiveness depends on taking the doses on a precise schedule.

Because melatonin products are nutritional supplements rather than prescription drugs, the claims made by the manufacturers have not undergone rigorous scrutiny, and the quality of each formulation may vary.

Psychologic Stress

Fear of flying and claustrophobia can cause distress. Hypnosis and behavior modification help some people. Taking a sedative may relieve fears before and during a flight.

Because the behavior of some mentally ill people worsens during airplane flights, those with violent or unpredictable tendencies must be accompanied by an attendant, and they may need to take a sedative before the flight.

General Precautions

Cardiac pacemakers and metal artificial limbs, plates, or pins are affected by airport metal detectors used to scan for concealed weapons; however, newer models of pacemakers can withstand potential interference from such detectors. To avoid security problems, people who wear such devices should carry a doctor's note explaining the situation.

The risk of developing blood clots in the legs is increased in anyone who sits in one place for a long time. Pregnant women and people who have poor circulation are at particular risk. Walking around the airplane cabin every hour or two and contracting and relaxing the leg muscles while sitting help keep the blood flowing.

Dehydration, resulting from the low humidity (about 5 percent) in the cabin, can be prevented by drinking enough liquids and avoiding alcohol, which makes dehydration worse. People who wear contact lenses should apply rewetting solution to their lenses frequently to combat the effects of dry air.

Special foods, including low-salt, low-fat, and diabetic diets, are usually available from an airline by advance request.

Travelers should pack drugs in a carry-on bag rather than in a suitcase checked at the airport, in case their luggage is lost, stolen, or delayed. Drugs should be kept in their original containers. Travelers who must carry narcotics, large amounts of any drug, or syringes should have a doctor's note to avoid being detained by security or customs officers. Travelers may wish to carry a summary of their medical records, including electrocardiogram results, in case they become ill while away from home. Those who have a potentially disabling condition, such as epilepsy, should wear a Medic Alert identification bracelet or necklace.

Women with normal pregnancies can travel by air through the eighth month. Women with highrisk pregnancies should discuss their travel plans with their doctor and obtain approval before flying. Generally, air travel during the ninth month requires a doctor's note dated within 72 hours of departure and indicating the woman's anticipated date of delivery. Seat belts should be worn low across the thighs, not over the abdomen, to prevent injury to the uterus.

Infants under 7 days old aren't permitted to fly. Children with chronic diseases, such as congenital heart or lung diseases or anemia, have the same restrictions as adults with those conditions. There's no upper age limit for travel.

Airlines make reasonable efforts to accommodate the handicapped. Often, wheelchairs and stretchers can be accommodated on commercial flights; otherwise, air ambulance service is necessary. Some airlines accept people who need special equipment such as intravenous lines and mechanical respirators as long as trained personnel accompany them and arrangements have been made at least 72 hours in advance.

Information and advice about air travel can be obtained from the medical departments of major airlines or from the Federal Aviation Administration Regional Flight Surgeon.

Foreign Travel

Of the millions of people who travel or work abroad every year, about I out of 30 needs medical attention for an illness or injury. Gastrointestinal infections may result from drinking contaminated water, including ice, and beverages or eating uncooked or improperly cooked foods. Casual sexual contacts produce a high risk for contracting the human immunodeficiency virus (HIV), which exists worldwide, as well as other sexually transmitted diseases. Motor vehicle accidents, especially at night, and drowning are the leading causes of death or injury for travelers in foreign countries. Health risks vary according to country and region; the Centers for Disease Control and Prevention provides up-to-date health advisories.

In foreign countries, many insurance plans, including Medicare, are not valid, and hospitals often require a substantial cash deposit, regardless of health insurance held in the United States. A variety of travel insurance plans, including some that arrange for emergency evacuation, are available through travel agents and some credit card companies. Directories listing English-speaking doctors in foreign countries are available from several organizations, and United States consulates may help secure emergency medical services.

Vaccinations

People planning a trip to another country should have the appropriate vaccinations, depending on their destination. In general, more preparation is needed when the trip lasts longer than 3 weeks, has several destinations in developing countries, or involves travel in rural areas or working with resident populations. Requirements for vaccinations change frequently. Some vaccinations must be given 2 to 12 weeks before the trip, so a traveler should inquire about vaccinations in advance. Information about vaccination requirements is available from various sources.